critical care delivery in the intensive care unit: deﬁning clinical roles and the best practice...

Critical care delivery in the intensive care unit: Defining clinicalroles and the best practice model

Richard J. Brilli, MD, FCCM; Antoinette Spevetz, MD, FCCM; Richard D. Branson, RRT, FCCM;Gladys M. Campbell, RN, MSN, FCCM; Henry Cohen, PharmD, MS; Joseph F. Dasta, MSc, FCCM;Maureen A. Harvey, RN, MPH, FCCM; Mark A. Kelley, MD; Kathleen M. Kelly, MD, FCCM;Maria I. Rudis, PharmD, FCCM; Arthur C. St. Andre, MD, FCCM; James R. Stone, MD, FCCM;Daniel Teres, MD, FCCM; Barry J. Weled, MD, FCCM; the members of the American College of CriticalCare Medicine Task Force on Models of Critical Care Delivery*; the members of the American College ofCritical Care Medicine Guidelines for the Definition of an Intensivist and the Practice of Critical CareMedicine‡

Patients receiving medical carein intensive care units (ICUs)account for nearly 30% ofacute care hospital costs, yet

these patients occupy only 10% of inpa-tient beds (1, 2). In 1984, the Office ofTechnology Assessment concluded that80% of hospitals in the United States hadICUs, �20% of hospital budgets were ex-pended on the care of intensive care pa-tients, and approximately 1% of the grossnational product was expended for inten-sive care services (3). With the aging ofthe U.S. population, greater demand forcritical care services will occur. At the

same time, market forces are evolvingthat may constrain both hospitals’ andpractitioners’ abilities to provide this in-creasing need for critical care services. Inaddition, managed care organizations arerequesting justification for services pro-vided in the ICU and for demonstration ofboth efficiency and efficacy. Hospital ad-ministrators are continually seekingmethods to provide effective and efficientcare to their ICU patients. As a result ofthese social and economic pressures,there is a need to provide more dataabout the type and quality of clinical careprovided in the ICU.

In response, two task forces were con-vened by the Society of Critical Care Med-icine leadership. One task force (modelstask force) was asked to review availableinformation on critical care delivery inthe ICU and to ascertain, if possible, a“best” practice model. The other taskforce was asked to define the role andpractice of an intensivist. The task forcememberships were diverse, representingall the disciplines that actively participatein the delivery of health care to patientsin the ICU. The models task force mem-bership consisted of 31 healthcare profes-sionals and practitioners, including stat-isticians and representatives fromindustry, pharmacy, nursing, respiratorycare, and physicians from the specialtiesof surgery, internal medicine, pediatrics,and anesthesia. These healthcare profes-sionals represented the practice of critical

care medicine in multiple settings, in-cluding nonteaching community hospi-tals, community hospitals with teachingprograms, academic institutions, militaryhospitals, critical care medicine privatepractice, full-time academic practice, andconsultative critical care practice.

This article is the consensus report ofthe two task forces. The objectives of thisreport include the following: (1) to de-scribe the types and settings of criticalcare practice (2); to describe the clinicalroles of members of the ICU healthcareteam (3); to examine available outcomedata pertaining to the types of criticalcare practice (4); to attempt to define a“best” practice model; and (5) to proposeadditional research that should be under-taken to answer important questions re-garding the practice of critical care med-icine.

The data and recommendations con-tained within this report are sometimesbased on consensus expert opinion; how-ever, where possible, recommendationsare promulgated based on levels of evi-dence as outlined by Sacket in 1989 (4)and further modified by Taylor in 1997(5) (see Appendix 1).

DEMOGRAPHICS ANDPATTERNS OF CARE IN ICUSIN THE UNITED STATES

Several databases have described thedemographics and patterns of care inICUs in the United States. This section

The American College of Critical Care Medicine(ACCM), which honors individuals for their achieve-ments and contributions to multidisciplinary criticalcare medicine, is the consultative body of the Societyof Critical Care Medicine (SCCM) that possesses rec-ognized expertise in the practice of critical care. TheCollege has developed administrative guidelines andclinical practice parameters for the critical care prac-titioner. New guidelines and practice parameters arecontinually developed, and current ones are system-atically reviewed and revised.

Address requests for reprints to Richard J. Brilli,MD, FCCM, Division of Critical Care Medicine, OSB-5,Children’s Hospital Medical Center, 3333 Burnet Ave-nue, Cincinnati, OH 45229. E-mail: [email protected]

*See Appendix 6 for a complete listing of mem-bers.

‡See Appendix 7 for a complete listing of mem-bers.

Key Words: critical care nurse; intensive care unit;intensivist; organizational characteristics; outcome;outcomes assessment; pharmacist; practice patterns;respiratory therapist

Copyright © 2001 by Lippincott Williams & Wilkins

2007Crit Care Med 2001 Vol. 29, No. 10

describes the methods used to establishthese databases and their major findings,focusing primarily on critical care prac-tice patterns.

Society of Critical CareMedicine Study (1991)

In 1992 and 1993, the Society of Crit-ical Care Medicine (SCCM) reported theresults of a 1991 survey of all ICUs in theUnited States (6, 7). The American Hos-pital Association provided the databaseused for the survey. The survey responserate was 40%, with 1,706 hospitals pro-viding data on 2,876 separate ICUs with32,850 ICU beds and 25,871 patient ad-missions. The survey demonstrated thatnationally, 8% of all licensed hospitalbeds were designated as intensive care.Adult and pediatric ICUs averaged 10–12beds per unit, whereas neonatology unitsaveraged 21 beds. Overall, ICU occupancyaveraged 84% of total ICU beds. Smallhospitals with �100 beds usually hadonly one ICU, whereas larger hospitals,particularly those exceeding 300 beds,tended to have multiple ICUs, most com-monly designated as medical, surgical,and coronary care.

Management and organizationalstructure varied widely. Departments ofmedicine had responsibility for 36% ofthe ICUs, whereas 22% had no formaldepartmental affiliation. Internists di-rected 63% of all ICUs. Most surgical andneurologic units were directed by sur-geons, as were 21% of the mixed medical/surgical units. Full-time unit directorswere present in 20% to 60% of the dif-ferent hospitals surveyed. The smallerhospitals (�100 beds; 20% had full timedirectors) were less likely to employ afull-time unit director compared withlarger hospitals (�500 beds; 60% had fulltime directors). Further findings indi-cated that 61% of directors were part-time, 51% were unpaid, and 56% werenot certified in critical care medicine.Smaller hospitals (20%) had a lower per-centage of board-certified unit directorscompared with larger hospitals (56%).The ICU medical director, or designee,authorized admissions to the ICU in 12%of all the ICUs surveyed. Pediatric (31%),neonatal (30%), and surgical units (20%)were most likely to have medical direc-tors who authorized unit admissions. Ashospital size increased, the likelihoodthat the unit director had final authorityregarding admissions also increased. Inhospitals with �100 beds, the unit direc-

tor had such authority in 9% of the hos-pitals, whereas in hospitals with �500beds, this authority was present in 56%.Responsibility for patient care was trans-ferred to the ICU service in 15% of allunits surveyed. The ICU service had ex-clusive medical order-writing authorityin 22% of the units (closed unit). Openunits were those in which any physiciancould write orders. Resident physiciansdedicated to the ICU were present in 6%of the smallest hospitals compared with95% in the largest hospitals. The percentof nurses that were certified as criticalcare RNs increased as hospital size in-creased: 16% �100 beds; 21% �500beds. Forty-eight percent of units re-ported having dedicated respiratory ther-apists, with a median of two therapistsper unit.

Pediatric ICU Survey Data(1989)

In 1993, the results of telephone sur-veys conducted in 1989 of all pediatricICUs in the United States were published(8). Of 301 hospitals initially believed tohave pediatric ICUs (PICUs), data werecollected from 235 (78%). Most PICUshad four to six beds (40%). Only 6% had�18 beds. The ICU mortality rate differedsignificantly among ICU size groups, withthe largest units having the highest mor-tality (7.8 � 0.8%). Full-time ICU medi-cal directors were present in 80% of thehospitals. In 64% of the units, the medi-cal director or designee was involved inthe care of �90% of the patients. A con-sistent charge nurse was available in90.6% of the units.

Committee on Manpower forthe Pulmonary and Critical CareSocieties (COMPACCS; 1997)

To document current and futureneeds for critical care and pulmonaryspecialists, the American Thoracic Soci-ety, the American College of Chest Phy-sicians, and the SCCM organizedCOMPACCS in 1995. As part of this study,random samples of hospitals and hospi-tal-appointed ICU directors were sur-veyed. Pediatric ICUs and units desig-nated as cardiac care were excluded fromthe COMPACCS survey.

In the survey, ICU directors describedthe characteristics of their units and pa-tients on the day the survey was com-pleted. To characterize the role of inten-sivists in ICU care, the ICU directors used

the following definitions to describe thecare provided to their patients.

a) Full-time intensivist model, whereinall or most of a patient’s care is di-rected by an intensivist (where an in-tensivist was defined as an attendingphysician who, by training or experi-ence, provides care for the critically illin a role broader than that provided bya consultant specialist).

b) Consultant intensivist model, whereinan intensivist consults for anotherphysician to coordinate or assist incritical care but does not have primaryresponsibility for care.

c) Multiple consultant model, whereinmultiple specialists are involved in thepatient’s care (a pulmonologist or in-tensivist might be consulted for ven-tilator management, but no one isdesignated specifically as the consul-tant intensivist).

d) Single physician model, wherein theprimary physician provides all ICUcare without involvement of an inten-sivist or other consultant.

General ICU Statistics. At the time ofthe survey, there were 5,979 noncoronaryICUs in the United States, consisting of72,500 beds with an average occupancy of77% (average number of beds per unitwas 12, with an average census of 9.2).The large majority of ICU beds and pa-tients were in general medical or generalsurgical units, with an approximate na-tional ICU census, in the spring of 1997,of about 53,000 patients (personal com-munication; 9).

Patterns of Care. Nearly all of the pa-tients described in the survey could beclassified into one of the four patterns ofmedical care described previously. Of the53,000 patients, 23.1% were treated in anICU utilizing the full-time intensivistmodel, 13.7% utilizing the consultant in-tensivist model, 45.6% using the multipleconsultant specialist model, 14.2% usingthe single physician model, and 3.4% us-ing some other model. The demographicsof the care patterns are described in Table1 (personal communication; 9).

Regression analysis of these data indi-cate that the use of the full-time inten-sivist was statistically associated withlarger hospitals, higher managed carepenetration, and medical ICUs (MICUs).There was no consistent relationship be-tween patient population size and thefull-time intensivist model.

ICU Organization and Staffing. Of allICUs surveyed, the administrative re-

2008 Crit Care Med 2001 Vol. 29, No. 10

sponsibility was assigned to clinical de-partments as follows: anesthesia, 0.6%;medicine, 36.7%; surgery, 16%; freestanding, 29.1%; and other, 17.6%. In-tensivists provided clinical care in 60% ofsurveyed ICUs, with an average of 12.7staff members identified by the ICU direc-tor as intensivists. Training and/or boardcertification in critical care were com-mon for these intensivists, ranging froman average of 50% for general interniststo 88% for pulmonologists.

In-hospital physician coverage varied.Hospital staff physicians, in roles that var-ied from attending physician to admittingphysician to emergency back-up physician,were formally assigned to cover 30% of theICUs. During daytime hours on weekdays,this role was fulfilled, on average, by 3.6staff physicians geographically assigned asfollows: full-time presence in the ICU, 27%;presence elsewhere in the hospital, 44%; orpresence off-site, 24%. On nights and week-ends, 70% of the full-time coverage wasdirected from off-site and, on average, bytwo staff physicians. Residents were as-signed to cover 44% of all ICUs. Residentswere assigned full-time ICU coverage in53% of hospitals surveyed, in-hospital pres-ence with ICU cross-coverage in 42%, andother in 5%. Fellows were assigned to cover21% of the ICUs surveyed, with 47% full-time in the ICU, 40% cross-coverage in thehospital, and the remainder off site. Lessthan 10% of surveyed ICUs reported usingnurse practitioners or physician assistants.This coverage almost always required theirpresence in the hospital, and approximatelyhalf of this coverage was full-time in theICU.

From these data, generated from sur-veys conducted about 10 yrs apart andprimarily in adult critical care units,

there are some consistent patterns. Aboutone third of the ICUs are administered bythe department of medicine, one-fourthhave no departmental affiliation, and60% of all ICU patients are in general ICUunits. The full-time intensivist treated23% of all ICU patients. This role wasparticularly common in large hospitalsand especially in MICUs. House staff andfellow coverage were employed in 44%and 21% of all ICUs, respectively. In con-trast, ICU coverage by nonphysicians wasvery uncommon.

CRITICAL CARE PRACTICEMODELS

Multidisciplinary Critical Care

The information derived from theaforementioned surveys can be used todescribe various models of critical carepractice. In a joint position statement,published in 1994, SCCM and the Amer-ican Association of Critical Care Nursesadvocated for a multidisciplinary ap-proach to the administrative and clinicalpractice of intensive care medicine (1, 10,11). The governing bodies of the organi-zations espoused collaboration andshared responsibility for ICU team lead-ership as a fundamental part of optimiz-ing the medical care provided to criticallyill patients. Carlson et al. (12) furtheroutlined five characteristics of the multi-disciplinary, collaborative approach toICU care:

1. Medical and nursing directors withauthority and co-responsibility for ICUmanagement.

2. Nursing, respiratory therapy, andpharmacy collaboration with medicalstaff in a team approach.

3. Use of standards, protocols, and guide-lines to assure consistent approach tomedical, nursing, and technical issues.

4. Dedication to coordination and com-munication for all aspects of ICU man-agement.

5. Emphasis on practitioner certifica-tion, research, education, ethical is-sues, and patient advocacy.

This multidisciplinary approach to themanagement of critically ill patients maybe an important factor in the quality ofcare provided in the ICU. The presence ofa team of health professionals from vari-ous disciplines, working in concert, mayimprove efficiency, outcome, and the costof care for patients hospitalized in theICU (12–31). An essential element of theability of a multidisciplinary team to ef-fectively attain specified objectives isteam dynamics. Only recently has the im-pact of team dynamics been applied tomedical care delivery teams, and it is im-portant to note that team dynamics maydiffer given the time allowed to accom-plish the objective (i.e., emergently, ur-gently, routine). As a result, in the ICU, itis essential that the physician team leaderand the critical care nurse manager col-laborate in the education, structure, andevaluation of the team’s dynamics (32,33).

A detailed description of this multidis-ciplinary approach to critical care prac-tice has been further outlined by recentAmerican College of Critical Care Medi-cine (ACCM) and American Academy ofPediatrics recommendations for servicesand personnel required to provide criticalcare medicine to adults and children hos-pitalized in ICUs (34, 35). These recom-mendations represent the consensus re-port of experts in critical care medicine.

Certain aspects of the document per-taining to adult ICUs require clarificationto highlight the recommendations andsupport for the multidisciplinary ap-proach to critical care medicine (34).

1. Comprehensive critical care unitsshould be directed by an intensivist, asdefined by the SCCM, in collaborationwith a defined nursing director (36).

2. Patient management should be di-rected by an attending physician whois credentialed by the hospital medicalstaff to provide care to critically illpatients.

Table 1. Demographics of care patterns

Full-TimeIntensivist

ConsultantIntensivist

ConsultantSpecialist

SinglePhysician

Hospital sizeSmall 12a 07 50 30Medium 09 14 55 20Large 40 14 37 04Very large 36 19 34 10

Type of ICUGeneral (33,112)b 19 13 46 17MICU (16,752) 47 17 33 03SICU (7,510) 21 18 45 14Specialty (5,455) 21 13 52 14

ICU, intensive care unit; MICU, medical ICU; SICU, surgical ICU.aValues reflect percent of total care provided by each model in each row; total may not add up to

100% because “other” category was not included in the table; bnumbers in parentheses represent thetotal patients nationally in that category.


3. Critical care attending physiciansshould be available to provide bedsidecare within 30 mins, and in-hospitalICU physician coverage must have suf-ficient expertise to provide emergencymanagement including, but not lim-ited to, airway emergencies.

4. All nursing care should be provided bycritical care trained nurses.

5. Respiratory therapists with a workingknowledge of the principles of respira-tory failure management should bededicated to the ICU 24 hrs per day.

6. Pharmacy services should be availableto provide ICU-dedicated pharmaceu-tical care and consultation.

In the pediatric document, publishedjointly in 1993 by the American Academyof Pediatrics and SCCM, the multidisci-plinary approach to critical care medicineis described for the pediatric ICU. Char-acteristics of the medical and nursing di-rectors, types and availability of physicianstaffing, and availability of a dedicatedteam of healthcare practitioners specifi-cally trained in the area of pediatric med-icine are described (35). A state govern-ment, in formulating statewide qualitystandards for PICUs regarding equip-ment, space, and personnel (37), has rec-ognized the multidisciplinary approachto pediatric critical care medicine, out-lined in this article.

Physician Component—TheIntensivist

In 1992, the SCCM guidelines com-mittee described the functions of and re-quirements to be an intensivist (36). Spe-cific qualifications and responsibilities foran intensivist are outlined in Appendix 2.The most important role of the physicianintensivist on the critical care team is asthe coordinator and leader of the multi-disciplinary, and often multispecialty, ap-proach to the care of the critically illpatient. The critically ill patient is definedas any patient who is at risk for decom-pensation or any patient who is physio-logically unstable, requiring constantsurveillance and minute-to-minute titra-tion of therapy according to the evolutionof the disease process. The geographiclocation of the patient in the hospitaldoes not limit the need for critical care,but rather, it is the nature of the illnessthat defines the care needed. The treat-ment of the critically ill patient beginsimmediately on recognition of the sever-ity of illness, continues as the patient is

transferred into the ICU, and extends intothe recovery phase until the potential fordecompensation is sufficiently low.

An intensivist is responsible for coor-dinating and providing integrated care tothe patient with acute and chronic com-plex illnesses. To accomplish this, prox-imity to the patient is required. Duringscheduled intervals, the intensivist prac-titioner must be immediately available tothe patient in the ICU and have no higherpriority that would interfere with theprompt delivery of patient care. At times,other specialty consultation is necessary.When multiple consultants are involved,the intensivist, acting as the multispe-cialty team leader, coordinates the careprovided by the consultants, thus provid-ing an integrated approach to the patientand family.

The intensivist participates in and co-ordinates ICU management activitiesnecessary for the safe, efficient, timely,and consistent delivery of care. Key tothese ICU management responsibilities isvesting the authority and providing re-sources and administrative medical staffleadership. These responsibilities includethe following: 1) patient triage based onadmission and discharge criteria, bed al-location, and discharge planning; 2) de-velopment and enforcement of, in collab-oration with other ICU team disciplines,clinical and administrative protocols thatare intended to improve the safe and ef-ficient delivery of clinical care and tomeet regulatory requirements; 3) coordi-nation and assistance in the implementa-tion of quality improvement activitieswithin the ICU.

The intensivist takes a lead role inmeeting the emotional and informationalneeds of the family during a patient’sadmission to the ICU. He/she facilitatesand collaborates with other team mem-bers to provide support for the family inconjunction with that of nursing, minis-terial services, and social service teammembers. The intensivist has the skills tocounsel families and to address ethicalissues of care by providing the familywith the knowledge and support that isneeded to make informed decisions re-garding the patient’s care. This includes,but is not limited to, end-of-life decisions.

The physician component of criticalcare practice can assume several pat-terns. Categorizing critical care practicepatterns is difficult because there aremany variations depending on institu-tional bias, geographic distribution ofphysician manpower, and regional avail-

ability of financial resources. These crit-ical care practice patterns begin by de-scribing the physician intensivist role inthe coordination of care for critically illpatients and often further describe theinterrelationships between the physicianintensivist and ICU administrative struc-ture.

Much of the medical literature catego-rizes ICUs as “open” or “closed.” Theseterms have been defined in several ways.In the analysis published by Groeger et al.(6), open refers to units wherein any phy-sician could write medical orders andclosed refers to units wherein only theICU physician staff could write medicalorders. Others have defined the terms ina broader context and added a third typeof unit called “transitional” (12, 38). Asdescribed by Carlson et al. (12), and fur-ther adapted here, the characteristics, ad-vantages, and disadvantages for the unitsare outlined below.

Open Units. Any attending physicianwith hospital admitting privileges can bethe physician of record and direct ICUcare; the presence or absence of a dedi-cated intensivist physician and nursingunit directors; the presence of ICU-dedicated house officers variable; the po-tential for duplication of services, thelack of a cohesive plan, and inconsistentnight coverage.

Closed Units. An intensivist is the phy-sician of record for all ICU patients; full-time ICU directors (physician and nurs-ing); house officers usually present andusually full-time dedicated to the ICU; allorders and procedures carried out by ICUstaff; potential for improved efficiencyand standardized protocols for care; po-tential to lock-out private physicians andincrease physician conflict.

Transitional Units. An intensivist di-rector, trainees, and intensivist team arepresent as locally available; standard pol-icies and procedures usually present;shared co-managed care between ICUstaff and private physician; encouragesoptimal communication between ICUstaff and community physician; may re-duce physician conflict; ICU staff is thefinal common pathway for orders andprocedures; potential for confusion andconflict regarding who has final authorityand responsibility for patient care deci-sions.

ACCM has also described practice pat-tern models and definitions as follows(personal communication).

Attending Physician of Record. An ICUis an “open unit” when any attending


physician with appropriate hospital ad-mitting privileges can be the patient’sphysician of record and has ultimate re-sponsibility for the quality and coordina-tion of care. All other physicians are con-sultants. An ICU is “closed” when theintensivist automatically becomes the at-tending physician of record for all pa-tients admitted to the ICU. All other phy-sicians are consultants.

Physician Commitment. There can bea spectrum of commitment to the ICU.One example includes the full-time inten-sivist group of physicians, geographicallydedicated to the 24-hr coverage of theICU, wherein a qualified physician is im-mediately available to the ICU and has noclinical commitments other than theICU. In contrast are physicians who pro-vide intermittent coverage by makingrounds and responding to emergenciesbut who also have simultaneous clinicalresponsibilities other than the ICU.

It is the assertion of this task forcethat the aforementioned ACCM defini-tions and those described by Carlson etal. (12) encompass nearly all patterns ofmedical practice in the ICU setting thatpertain to the physician-patient practicepattern. In examining outcome data,these unit classifications and physicianpractice patterns are often cited, and assuch, the definitions are important.

Nursing Component

Although an in depth description ofcritical care nursing practice is beyondthe scope of this document, specific stan-dards of care and practice are outlined inAppendix 3. The section below describesnursing practice in the ICU, focusing onthe relationship between nursing andphysician practice in the ICU.

Critical care nursing traditionally in-cludes, but is not limited to, the roles ofstaff nurse, nurse manager, clinical nursespecialist, and acute care nurse practitio-ner. Critical care nursing practice focuseson several areas.

1. Understanding and supporting techni-cal medical care, including diagnosis,treatment, care planning, and prioritysetting. In this role, the nurse part-ners with the ICU attending physicianto provide care and oversight to theplan of care ensuring that consultantsand ancillary care providers demon-strate practice consistent with thisplan. The nurse ensures that the at-tending physician is aware of changes

in the patient’s condition and that in-terventions are consistent with ac-cepted standards of practice.

2. Hospital systems expertise include or-ganizational leadership, implementa-tion of unit-based protocols, qualityimprovement expertise, and analysisof data from outcome pathways, staffand patient satisfaction, and sentinelevents.

Critical care nurses do the majority ofpatient assessment, evaluation, and carein the ICU. The ratio of patients to bed-side nurses is typically 2:1. This allowsthe critical care nursing staff to spendseveral hours per patient per shift collect-ing and integrating information and in-corporating it into meaningful patientcare. Through their caring practices, theyimprove the ICU experience for both pa-tients and their families, and throughtheir critical thinking skills, experiencednurses readily recognize clinical changesto prevent further deterioration in thesepatients. They are familiar with the com-plications that may be seen in these pa-tients and attempt to prevent them.When practicing in a multiple consultantmodel, nurses are often faced with recon-ciling competing orders and unclear linesof both authority and responsibility forpatient care.

An advanced practice nurse (APN) is anurse who has received education at thegraduate level, or higher. APNs providehealth care to patients and families andmay demonstrate a high level of indepen-dence. Advanced practice nurses collabo-rate with the critical care team in devel-oping and implementing a plan of carethat is dynamic. In some ICUs, the APNmay alter the plan of care. APNs combineclinical practice with education, research,consultation, and leadership. APNs, in-cluding clinical nurse specialists andnurse practitioners, teach and mentornursing staff, educate patients and fami-lies, and create teaching materials for aspecific type of patient. Counseling fam-ilies about the short- and long-term man-agement of a patient’s illness is an impor-tant component of the practice of anAPN.

Pharmacy Component

Appendix 4 and a review by Rudis et al.(39) describe specific details of pharma-cists’ responsibilities in the ICU. Generalresponsibilities of the pharmacist in theICU include comprehensive monitoring

of medication usage to provide cost-effective pharmacotherapy and to inter-vene as necessary in the medication de-livery process to maximize patientoutcomes. The pharmacist and pharmacyservices may function from an ICU satel-lite pharmacy or from centralized phar-macy services. Pharmacists participate indrug therapy evaluations either prospec-tively (before a medication order) or ret-rospectively (after the medication order).Based on institutional resources, thepharmacist’s responsibility in providingpharmacotherapy services is fulfilled us-ing several different practice models.

In one model, pharmacists retrospec-tively evaluate medication orders butusually do not attend ICU rounds. In asecond model, pharmacists are assignedto a critical care satellite pharmacy, withsimultaneous responsibilities includingdispensing of medications, prospectiveevaluation of medication orders, and at-tending ICU rounds. In a third model,pharmacists are exclusively assigned todirect patient care responsibilities, in-cluding attending daily unit rounds, ob-taining medication histories, and pro-spectively evaluating drug therapy.Pharmacist consultative services in phar-macotherapy, nutrition support, or phar-macokinetics may be available as anadded service to any of the practice mod-els.

Respiratory Therapy Component

The role of the respiratory care prac-titioner as an integral member of the ICUclinical team focuses primarily on man-agement of the patient/ventilator system,airway care, delivery of bronchodilators,monitoring of hemodynamics and bloodgases, and the delivery of protocol-regulated respiratory care. As outlinedbelow, several trials have demonstratedthe importance of respiratory care prac-titioners in facilitating weaning from me-chanical ventilation and improving theallocation of respiratory care services.

Current evidence suggests that respi-ratory therapist-directed ventilator wean-ing, via protocol, results in a shorterduration of mechanical ventilation com-pared with traditional physician-directedweaning. Additional benefits include re-duced costs, a decrease in nonlethal com-plications, and reduced re-intubationrates (21–25). These trials represent pro-spective, randomized, controlled trials insingle institutions using concurrent con-trols and demonstrate the value of the


integration of respiratory therapy intothe healthcare team in the ICU. In addi-tion, resource allocation is improved withrespiratory therapist-driven protocols tooptimize equipment and personnel utili-zation (26–30).

OUTCOME DATA—MODELSAND PATTERNS OF CRITICALCARE PRACTICE

Overall Assessment of theLiterature

There are numerous problems associ-ated with evaluation and comparison ofthe medical literature regarding modelsand patterns of critical care delivery. Re-cent literature, focused primarily on theorganization of the physician’s role at thebedside or unit level, has created dispar-ate views of unit organization. Is there acritical care team? Is the ICU open orclosed? Should there be 24-hr in-housecoverage? There are often large differ-ences among MICUs, surgical ICUs, andpediatric ICUs. There are differencesamong highly specialized university hos-pitals, regional community tertiary facil-ities, and small to medium nonteachingcommunity hospitals. There are differ-ences between ICUs in cities and in ruralsettings, as well as in large urban inner-city facilities.

In addition, there are multiple con-founding factors, usually not addressed inthe literature, that further complicateany analysis of outcomes based on modelsof critical care practice. These confound-ing variables include the presence or ab-sence of nonphysician providers, quality,quantity, and type of bedside nursingcare, regionalization of medical care, andlack of standard definitions for ICU ad-ministrative management. Few studiesaddress differences among various mid-level care providers, such as house staff,fellows, acute care nurse practitioners,physician assistants, critical care nursespecialists, respiratory therapists, phar-macists, and nutritionists. There are fewstudies dealing with different bedsidenursing patterns or personnel composi-tion, such as licensed practical nurses,masters trained nurses, certified criticalcare nurses, ICUs with stable nursing pat-terns, those with shortages at night or onweekends, or those that have high use of“traveling” nurses. There are few studiesrelated to regionalization, or remote crit-ical care attending services via telemedi-

cine, or the impact of intermediate care(step-down/progressive care) on ICU out-come data. Measures are not well stan-dardized regarding the evaluation of ICUmanagement that could form the basis ofuseful comparisons of models of care.These measures should include an orga-nizational assessment of leadership, cul-ture, coordination, communication, con-flict management, and team cohesionand perceived unit effectiveness (40).Most standardized outcome measures ofseverity-adjusted mortality and resourceuse may not be sensitive to these man-agement measures. Few studies relateICU models of care to quality-of-life out-comes and patient/family/caregiver satis-faction. For families, continuity of carewith previously known and respectedphysicians would seem important. Alsofewer moves while in the hospital wouldlikely lead to high satisfaction scores(41). Despite the aforementioned limita-tions, there is an emerging literature thataddresses ICU outcome and the pattern ofpractice within the ICU.

Medline-PubMED and the CochraneLibrary were searched using the follow-ing key words: practice patterns; organi-zational characteristics; ICU; outcomesassessment; outcome; intensivist; phar-macist; critical care nurse; respiratorytherapist. Articles were abstracted for fur-ther review if they described outcome as-sessment attributed to or associated witha model of clinical critical care practice.Examining the bibliography of articlespreviously abstracted identified addi-tional references. By using this method-ology, 143 articles were identified. Thefollowing sections summarize the dataidentified that pertain to outcome andpractice patterns of critical care medi-cine. Some of the studies that describeoutcomes associated with specific practi-tioner types, but within an overall criticalcare practice model, are discussed sepa-rately.

Nonrandomized Studies

There are a number of small, nonran-domized studies primarily using histori-cal controls (level IV) that support thepresence of an intensivist in the ICU com-pared with a prior model without an in-tensivist. These studies were usually donewhen there was a change in ICU organi-zational structure, primarily the additionof an intensivist. ICU outcome data (usu-ally mortality) from a time period beforethe addition of the intensivist are com-

pared with data for a time period after theaddition of the intensivist. These studiessuggest that ICU mortality and cost arelower with an intensivist present in theICU. Although it is tempting to perform ameta-analysis, we do not believe this ap-proach would be productive because ofthe methodological problems associatedwith combining multiple studies with de-sign flaws into an analysis with a largenumber of patients and the same designflaws. We will, however, summarize thefindings of many of the individual studiesoutlined above. Data available only in ab-stract format have been omitted.

Reynolds NH, Haupt MT, Thill-Baharozian MC, et al: Impact of criticalcare physician staffing with septic shockin a university hospital medical intensivecare unit. JAMA 1988; 260:3446–3450(42) (level IV evidence)

In a retrospective review of MICUrecords, two consecutive 12-month peri-ods of time were compared. During thefirst time period, the ICU was withoutcritical care-trained faculty, and duringthe second time period, the ICU was su-pervised by critical care-trained faculty.Severity of illness scores were compara-ble during the two time periods. Mortal-ity was significantly decreased during thepostcritical care medicine time period.

Pollack MM, Katz RW, Ruttimann UE,et al: Improving the outcome and effi-ciency of intensive care: The impact of anintensivist. Crit Care Med 1988; 16:11(14) (level IV evidence)

This article was a retrospective reviewof PICU records comparing two time pe-riods with and without an intensivist. Agreater use of therapeutic monitoringand favorable effects on bed utilizationoccurred during the intensivist time pe-riod. No effect on mortality or length ofstay was demonstrated.

Brown JJ, Sullivan G: Effect on ICUmortality of a full-time critical care spe-cialist. Chest 1989; 96:127–129 (43) (lev-el IV evidence)

A retrospective review was conductedof two time periods (consecutive years) ina MICU, before and after the addition of atrained critical care specialist (intensiv-ist). Despite similar severity of illness, themortality rate was significantly lowerduring the intensivist time period.

Baggs JG, Ryan SA, Phelps CE, et al:The association between interdisciplinarycollaboration and patient outcomes in amedical intensive care unit. Heart Lung1992; 21:18–24 (44) (level IV evidence)


A prospective survey of nurses and res-idents in a MICU was conducted regard-ing their view of collaboration at the timeof ICU discharge. The nurse’s report ofcollaboration (nonvalidated survey tool)was positively correlated with patientoutcome after controlling for severity ofillness.

Pollack MM, Cuerdon TT, Patel KM, etal: Impact of quality of care factors onpediatric intensive care unit mortality.JAMA 1994; 272:941–946 (45) (level IIIevidence)

Data were collected from a nationalsurvey of 16 representative pediatricICUs. The ICUs differed significantly withrespect to descriptive statistics. Risk-adjusted mortality data indicated that thepresence of a pediatric intensivist was sig-nificantly associated with improved pa-tient survival. The presence of pediatricresidents was associated with an in-creased mortality risk. The conclusionsin this study have been challenged be-cause of the diverse nature of the ICUsstudied.

Carson SS, Stocking C, Podsadecki T,et al: Effects of organizational change inthe medical intensive care unit of a teach-ing hospital: A comparison of ‘open’ and‘closed’ formats. JAMA 1996; 276:322–328 (13) (level III evidence)

This was a prospective cohort studythat examined two consecutive time pe-riods of ICU care. The first encompassedan open ICU organizational structure,wherein critical care specialists consultedon all ICU patients and made recommen-dations, but the admitting attending phy-sician retained primary responsibility forpatient care. Under the closed format, thecritical care attending physician assumedprimary responsibility for all patient careand the admitting physician was a con-sultant. Despite significantly higher se-verity of illness scores during the closedICU organization, the risk-adjusted mor-tality score was 0.78 compared with 0.90in the open ICU organization. Resourceutilization did not increase during theclosed unit structure, despite higher se-verity of illness.

Pollack MM, Patel KM, RuttimannUE, et al: Pediatric critical care trainingprograms have a positive effect on pedi-atric intensive care mortality. Crit CareMed 1997; 25:1637–1642 (46) (level IVevidence)

This was a cohort study of 16 volun-teer PICUs (eight with PICU fellowshipsand eight without fellowships). PediatricICUs with fellowship training programs

had better risk-adjusted mortality ratescompared with those without trainingprograms.

Rosenthal GE, Harper DL, Quinn LM,et al: Severity adjusted mortality andlength of stay in teaching and nonteach-ing hospitals: Results of a regional study.JAMA 1997; 278:485–490 (47) (level IVevidence)

This was a retrospective cohort studyexamining 30 hospitals in Ohio. Risk-adjusted mortality and length of staywere lower in teaching hospitals com-pared with nonteaching hospitals.

Manthous CA, Amoateng-Adjepong Y,Al-Kharrat T, et al: Effects of medicalintensivist on patient care in a commu-nity teaching hospital. Mayo Clin Proc1997; 72:391–399 (48) (level IV evidence)

This was a retrospective review ofMICU patient admissions comparing twoconsecutive time periods before and afterthe addition of a medical intensivist. Pa-tient severity of illness was similar duringthe two time periods. Mortality for pneu-monia, mean length of hospital stay, andMICU stay were all reduced after the ad-dition of the medical intensivist.

Multz, AS, Chalfin DB, Samson IM, etal: A closed medical intensive care unit(MICU) improves resource utilizationwhen compared with an open MICU.Am J Respir Crit Care Med 1998; 157:1468–1473 (49) (level IV evidence)

A complicated methodology was used,wherein a retrospective analysis of twotime periods in one hospital was com-pared as the ICU administrative structurechanged from an open organizationalstructure to a closed one (retrospectiveanalysis). In addition, another cohort ofpatients was prospectively analyzed,wherein one group from one hospitalmanaged in an open ICU organizationalstructure was compared with anothergroup from another hospital managed ina closed ICU organizational structure(prospective analysis). Illness severity andprimary diagnostic categories betweengroups were comparable. ICU and hospi-tal length of stay was less in closed units.An open ICU format was associated withgreater mortality prediction.

Ghorra S, Reinert SE, Cioffi W, et al:Analysis of the effect of conversion fromopen to closed surgical intensive careunit. Ann Surg 1999; 229:163–171 (50)(level IV evidence)

This is a retrospective review compar-ing two time periods (open unit vs. closedunit) in a surgical ICU. Mortality andoverall complications were significantly

higher in the open-unit group comparedwith the closed-unit group.

Cole L, Bellomo R, Silvester W, et al:A prospective, multicenter study of theepidemiology, management, and out-come of severe acute renal failure in a“closed” ICU system. Am J Respir CritCare Med 2000; 162:191–196 (51) (levelIII evidence)

This was a prospective, observationalstudy examining the outcome of acuterenal failure requiring replacement ther-apy (severe acute renal failure) withinclosed ICU systems in Australia. Thestudy was conducted over a 3-month pe-riod in all nephrology units and ICUs inthe state of Victoria (all closed ICUs withcritical care physicians in charge of allpatients), Australia. Demographic, clini-cal, and outcome data using standardizedcase report forms were collected. By us-ing the SAPS II score or a recently vali-dated renal-failure specific score, the pre-dicted mortality for these patients wasshown to be 59%. Actual mortality was49.2%. The authors concluded that pa-tients with renal failure managed inclosed ICU systems in Australia had fa-vorable outcomes compared with pre-dicted mortality.

Blunt MC, Burchett KR: Out-of-hoursconsultant cover and case-mix-adjustedmortality in intensive care. Lancet 2000;356:735–736 (52) (level IV evidence)

A historical case control study exam-ined standardized mortality ratios in 452patients admitted to an ICU after an in-tensivist joined the staff compared with372 patients before the intensivist’s ar-rival. Severity of illness scores were com-parable in both groups; however, thestandardized mortality ratio improvedsignificantly in the intensivist group(0.81 vs. 1.11; ratio, 0.73 [95% confidenceinterval, 0.55–0.97]).

Practitioner-Specific Studies

Mitchell P, Armstrong S, Simpson T,et al: American Association of CriticalCare Nurses Demonstration Project: Pro-file of excellence in critical care nursing.Heart Lung 1989; 18:219–226 (53) (levelIV evidence)

This study demonstrated that im-proved patient outcomes were associatedwith nurse staffing levels, nurse creden-tials, model of nursing care delivery, amodel of shared or participative gover-nance, and the degree of collaborationbetween nursing and medicine.


Tarrow-Mordi WG, Hau C, Warden A,et al: Hospital mortality in relation tostaff workload: A 4-yr study in an adultintensive care unit. Lancet 2000; 356:185–189 (20) (level IV evidence)

This article describes a 4-yr study ofall admissions to an adult ICU in theUnited Kingdom, wherein adjusted mor-tality was more than two times higherwhen the nursing workload was highercompared with when it was lower.

Montazeri M, Cook DJ: Impact of aclinical pharmacist in a multidisciplinaryintensive care unit. Crit Care Med 1994;22:1044–1048 (19) (level III evidence)

This prospective observational studydescribes pharmacist interventions dur-ing a 3-month period in a medical-surgical ICU. During the study, therewere 10.7 � 5.0 pharmacist interventionsper day. These interventions includedproviding drug information to physiciansand nurses, drug order clarification,pharmacokinetic information, and ad-verse reaction reporting. The pharmacist-initiated therapeutic interventions re-sulted in significantly reduced drug costs($67,664.24 annualized) compared withhistorical controls.

Overall Best Studies in theLiterature

Pronovost PJ, Jenckes MW, DormanT, et al: Organizational characteristics ofintensive care units related to outcomesof abdominal aortic surgery. JAMA 1999;281:1310–1317 (54) (level III evidence)

This is a large observational, nonran-domized study using contemporaneouscontrols. The study was done using theMaryland Health Discharge Data Set,with a focus on patients undergoing ma-jor abdominal aortic surgery (n � 2987).The study compiled data from 39 of 46acute care hospitals in the state of Mary-land. The authors used a multitiered,multivariable analytic technique andshowed that daily rounds in the ICU by anICU physician was associated with re-duced in-hospital mortality and specificpostoperative medical complications. Themagnitude of this mortality reductionwas equivalent to that observed in otherstudies that compared the skill (and sur-gical volume) of operating surgeons. Theauthors used a validated survey instru-ment, completed by the ICU medical di-rector of participating ICUs, to definephysician organizational characteristics.There was a significant association be-tween reduced nurse-patient staffing on

the day and evening shifts and increasedresource use as estimated by increasedICU and hospital days. There are at leasttwo concerns with this study. One is thatthe authors could not detect a differencein mortality based on surgeon operatingvolume, an association that has been re-peatedly shown in many other studies.The second is that even in complex stud-ies, there is usually a suggestion of thefinal results found in the univariate ordemographic tables. In this study, thedescriptive tables and the univariate anal-yses presented did not seem to yield ob-vious or even subtle clues regarding whatwas ultimately shown with the multileveltechnique. The authors concluded thatdaily rounds by an ICU physician reducemortality and complications in the pa-tient population studied.

Leape LL, Cullen DJ, Demspey ClappM, et al: Pharmacist participation on phy-sician rounds and adverse drug events inthe intensive care unit. JAMA 1999; 282:267–270 (18) (level II evidence)

This is a controlled clinical trial exam-ining the incidence of preventable ad-verse drug events before and after theintroduction of a senior clinical pharma-cist (intervention) to the daily rounds inthe MICU. A medical coronary care unitwas used as a control unit. Preventableadverse drug events (attributable to pre-scribing errors) decreased by 66% afterthe intervention, whereas there was nochange in the rate of prescribing typedrug errors in the control unit.

Knaus WA, Draper EA, Wagner DP, etal: An evaluation of outcome from inten-sive care in major medical centers. AnnIntern Med 1986; 104:410–418 (55) (lev-el III evidence)

This study is the post hoc analysis ofthe original Acute Physiology andChronic Health Evaluation (APACHE) IIdatabase. This study was a large, nonran-domized observational study. There were13 hospitals and 5,030 patients used todevelop the APACHE II severity of illnesssystem. The authors rank ordered thehospital ICUs by the actual or observedmortality and the predicted hospitaldeaths. The ICUs’ medical or nursing di-rector completed a detailed questionnaireregarding staffing, organization, policies,procedures, and extent of the critical carepersonnel’s participation in patient care.The use of risk stratification with thestandardized mortality ratio demon-strated there were differences in the or-ganizational patterns that supported thehypothesis that the degree of coordina-

tion of intensive care services signifi-cantly influenced its effectiveness. Theorganizational patterns were related toboth the medical and nursing compo-nents. The rank ordering did not includea confidence interval, and it is likely thatthe statistical difference was primarily be-tween the top hospital and the bottomhospital. The top ICU was well organized,with protocols and policies including thecancelling of elective operating roomcases if no beds were available. There wasalso a high proportion of bedside nurseswho had master’s degree. In addition,there were no interns (postgraduateyear-1) in this unit. The bottom hospitaldid not have an organized medical pro-gram and had a substantial shortage ofnursing. There was an atmosphere of dis-trust, and there was no coordination ofcare. The APACHE III study with a largersample size and some attempt at enroll-ing representative hospitals was not ableto confirm the relationship between man-agement coordination and collaborationand severity-adjusted mortality out-comes. These analyses are problematicbecause it is difficult to evaluate the man-agement components of care in an objec-tive way. It is concluded that organizedICUs as defined in this review had lowermortality.

Hanson CW, Deutschman CS, Ander-son HL, et al: Effects of an organizedcritical care service on outcomes and re-source utilization: A cohort study. CritCare Med 1999; 27:270–274 (56) (levelIII evidence)

This study compared two differentconcurrent care models of surgical ICUpatients. One group was managed exclu-sively by the critical care attending ser-vice and the other by the general surgicalfaculty and house staff. Despite higherseverity of illness scores, the critical carepatient group had shorter ICU lengths ofstay, fewer days of mechanical ventila-tion, fewer arterial blood gases, fewerconsultations, fewer complications,shorter hospital lengths of stay, and fewerMedicare-adjusted charges. The criticalcare service model in this surgical ICUdemonstrated improved quality and cost.

Pronovost et al. (57), in a recent sys-tematic review of the available literatureregarding ICU physician staffing and out-comes, concluded that there is a consis-tent finding of decreased mortality andlength of stay with intensivist presence.Despite the aforementioned data, there isno randomized, prospective trial that ef-fectively compares outcome between var-


ious models of critical care delivery. In aneditorial in Critical Care Medicine, Hall(58) questions the interpretation of thecurrently available outcome data. Henotes that even if the differences are real,it remains unclear which components ofcare have resulted in the observed effects.He further suggests that future multicen-tered trials are clearly required.

WHAT IS THE BEST PRACTICEMODEL?

The analysis of any model of criticalcare delivery should be based on its abil-ity to minimize mortality and to optimizeefficiency while preserving dignity andcompassion for patients. Current litera-ture, although not clearly identifying a“best” practice model, does identify fac-tors that are related to improved outcomeas measured by reduced mortality, im-proved efficiency, decreased length ofstay, or decreased cost of care. These areas follows.

● Timely and personal intervention by anintensivist reduces mortality, reduceslength of stay, and decreases cost ofcare.

● In academic centers, the addition ofan intensivist to the critical careteam reduces mortality. It is not clearfrom the existing literature that24-hr full-time presence of an inten-sivist vs. an 8 –12 hr day is superior tohaving access to the intensivist in a“timely period.” Further researchmay clarify this point.

● When an intensivist is available in anadministrative role in the ICU provid-ing benchmarking, clinical research,and standardization of care, the datasuggest that length of stay, cost of care,and treatment complications can be re-duced.

● The presence of a critical care pharma-cist can decrease adverse drug eventsand reduce cost of care.

● Excessive nursing workload, as definedby hours per patient day or nurse/patient ratios, is associated with in-creased mortality in critically ill pa-tients.

● The presence of full-time respiratorycare practitioners dedicated to the ICUcan reduce length of ICU stay, shortenventilator days, and reduce overall ICUcosts.

RECOMMENDATIONS ANDCONCLUSIONS

The literature does not clearly supportone model of critical care delivery overanother; however, it does support a rec-ommendation for a model wherein dedi-cated ICU personnel, specifically the in-tensivist, the ICU nurse, respiratory carepractitioner, and pharmacist, all work asa team. Furthermore, this multidisci-plinary group practice model should beled by a full-time critical care-trainedphysician who is available in a timelyfashion to the ICU 24 hrs per day (grade Drecommendation).

While leading the critical care service,the intensivist physician should have nocompeting clinical responsibilities (gradeE recommendation).

ICUs with an exclusive critical careservice and operating in the closed for-mat, as described previously, may haveimproved outcomes. When geographicconstraints, resource limitations, andmanpower issues allow, this organiza-tional structure for the delivery of criticalcare services may be optimal (grade Erecommendation).

The presence of a pharmacist as anintegral part of the ICU team, includingbut not limited to making daily ICUrounds, improves the quality of care inthe ICU and reduces errors. The integra-tion of a dedicated pharmacist into theICU team is recommended (grade C rec-ommendation).

Physician practitioners in the ICUshould have hospital credentials to prac-tice critical care medicine. These creden-tials should incorporate both cognitiveand procedural competencies (expertopinion).

Additional study is crucial. Multi-center trials must be designed to answerquestions regarding what aspects of careare crucial to improved outcome. Towhat extent does administrative or proto-col implementation make a difference?Are complications reduced as a result ofcritical care team involvement? Does ad-ditional expertise immediately availableat the bedside provide the fundamentaleffect to improve outcome?

The SCCM research committee shouldorganize a multicentered, prospectivetrial, possibly in conjunction with otherorganizations, such as the American Tho-racic Society or the National Institutes ofHealth (NIH), to answer some of theaforementioned questions. A NIH con-sensus panel, similar to that organized

for the use of pulmonary artery catheters,may also be appropriate. As outlined atthe outset, it is imperative that criticalcare practitioners define what constitutesICU quality, how it should be measured,and delivered by what practice model.

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APPENDIX 1

Grading of Levels of Evidenceand Recommendations

Grading of recommendations

A � Supported by at least two level Iinvestigations

B � Supported by only one level Iinvestigation

C � Supported by level II investiga-tions only


D � Supported by at least one level IIIinvestigation

E � Supported by level IV or level Vevidence

Levels of evidence

Level I � Large, randomized trialswith clear-cut results; low risk of false-positive (�) error or false-negative (�)error

Level II � Small, randomized trialswith uncertain results; moderate tohigh risk of false-positive (�) and/orfalse-negative (�) error

Level III � Nonrandomized, concur-rent cohort comparisons, contempora-neous controls

Level IV � Nonrandomized, historicalcohort comparisons/controls, and ex-pert opinion

Level V � Case series, uncontrolledstudies, and expert opinion

APPENDIX 2

The Intensivist

This definition of an intensivist refersto physician credentials (1), process andfocus on care (2, 6, 7, 9, 10), scope ofexpertise (3, 4), availability (5, 6), andprofessional responsibility (8). An inten-sivist is as follows.

1. A physician who is trained and cer-tified through a primary specialtyand has successfully completed anAccreditation Council for GraduateMedical Education-approved train-ing program in critical care medi-cine and/or has a certificate of spe-cial qualification in critical care.

2. Diagnoses, manages, monitors, in-tervenes, arbitrates, and individual-izes the care to each patient at riskfor, in the midst of, or recoveringfrom critical illness.

3. Has the training and skills to man-age patients with multiple healthproblems derived from multiplecauses. These skills range on thecontinuum of care from acute resus-citation to management through therecovery phase of illness, includingbut not limited to the following.a. Hemodynamic instability, cardiac

failure, and cardiac dysrhythmiasb. Respiratory insufficiency or fail-

ure, with or without a need formechanical ventilatory support

c. Acute neurologic insult, includ-

ing treatment of intracranial hy-pertension

d. Acute renal failure or insuffi-ciency

e. Acute life-threatening endocrineand/or metabolic derangement

f. Drug overdoses, drug reactions,and poisonings

g. Coagulation disordersh. Serious infectionsi. Nutritional insufficiency requir-

ing nutritional supportj. End-of-life issues

Management of patients in the imme-diate perioperative period is as follows.

4. Is able to perform, manage, and co-ordinate the need for certain proce-dures including, but not limited tothe following.a. Maintenance of the airway in-

cluding tracheal intubation andmechanical ventilation

b. Placement of intravascular cath-eters and monitoring devices in-cluding the following1) Arterial catheters2) Central venous catheters3) Pulmonary artery catheters4) Temporary dialysis catheters

c. Placement and maintenance oftemporary pacing devices

d. Cardiopulmonary resuscitatione. Tube thoracostomyf. Other procedures that intensivists

may perform include therapeuticbronchoscopy, percutaneous tra-cheostomy, transesophageal echo-cardiography, renal replacementtherapy, cricothyroidotomy, EEG,and placement of intra-aortic bal-loon counterpulsation device.

5. Is immediately and physically availableto patients in the ICU and has no com-peting priority that would interferewith the prompt delivery of criticalcare during scheduled intervals whileacting as the clinical intensivist.

6. Participates in a unit-based, hospi-tal-approved coverage system thatprovides 24 hr a day availability byphysicians who possess similar cre-dentials in critical care.

7. Promotes quality and humane carein the ICU while maintaining effi-cient use of resources.

8. Furthers the practice of critical caremedicine through education of col-leagues and the public.

9. Provides unit-based administrativeduties that include but are not lim-ited to the following

a. Admission/discharge decisionsb. Treatment protocol development

and implementationc. Supervising and directing perfor-

mance improvement activitiesd. Maintaining up-to-date equip-

ment and techniquese. Responsible for unit-based data

collectionf. Promulgate links to other ancil-

lary departments that are in-volved in the care of the ICU pa-tient, e.g., pharmacy, radiology,infection control, social and pas-toral care, etc.

g. Responsible for approval of unit-based budget

10. Responsible for coordinating educa-tional needs for unit-based as well asgeneral hospital personnel and thepublic

APPENDIX 3

The Critical Care Nurse

The American Association of CriticalCare Nurses (AACN) provided much ofthe summary outlined below.

1. Is a licensed professional who is re-sponsible for ensuring that allacutely and critically ill patients re-ceive optimal nursing care. Basic tothe provision of optimal care is indi-vidual professional accountabilitythrough adherence to standards ofnursing care of acutely and criticallyill patients and a commitment to actin accordance with ethical princi-ples.

2. Clinical nursing practice varies con-siderably depending on the setting inwhich nurses are employed and thepatient population for which theyprovide care. The American Associa-tion of Critical Care Nurses Stan-dards for Acute and Critical CareNursing Practice provides the foun-dation for a minimum level of com-petent and professional care deliv-ered to critically ill patients in avariety of settings. Broad applicationof these standards by critical carenurses is expected to help promotequality care and positive patient out-comes.

3. Standards of care for acute and crit-ical care nursing are as follows.a. Assessment: The nurse caring for

the critically ill patient collectsrelevant patient health data.


b. Diagnosis: The nurse caring forcritically ill patients analyzes theassessment data in determining di-agnoses.

c. Outcome identification: The nursecaring for the critically ill patientidentifies individualized, expectedoutcomes for the patient.

d. Planning: The nurse caring for thecritically ill patient develops a planof care that prescribes interven-tions to attain expected outcomes.

e. Implementation: The nurse car-ing for the critically ill patientimplements interventions identi-fied in the plan of care.

f. Evaluation: The nurse caring forthe critically ill patient evaluatesthe patient’s progress toward at-taining expected outcomes.

4. Standards of Professional Practiceare as follows.a. Quality of care: The nurse caring

for the critically ill patient system-atically evaluates the quality andeffectiveness of nursing practice.

b. Individual practice evaluation: Thenurse’s practice reflects knowledgeof current professional standards,laws, and regulations.

c. Education: The nurse acquiresand maintains current knowledgeand competency in the care ofcritically ill patients.

d. Collegiality: The nurse caring forthe critically ill patient interactswith and contributes to the profes-sional development of peers andother healthcare providers as col-leagues.

e. Ethics: The nurse’s decision andactions on behalf of critically illpatients are determined in anethical manner.

f. Collaboration: The nurse caring forthe critically ill patient collaborateswith the team of patient, family,and healthcare providers in provid-ing patient care in a healing, hu-mane, and caring environment.

g. Research: The nurse caring forthe critically ill patient uses clin-ical inquiry in practice.

h. Resource utilization: The nursecaring for the critically ill patientconsiders factors related to safety,effectiveness, and cost in plan-ning and delivering patient care.

5. Certification is voluntary throughthe AACN Certification Corporation.The certified nurse receives a CCRN

credential available for nurses whocare for adults and pediatric and neo-natal patients.

APPENDIX 4

The ICU Pharmacist

1. Is a practitioner who is licensed bythe State Board of Pharmacy and hasspecialized training or practice expe-rience providing pharmaceuticalcare for the critically ill patient.

2. In providing pharmaceutical care isresponsible for administering thefollowing services.a. Evaluation of all drug therapy for

appropriate indication, dose,route, and dosage form

b. Evaluation of all drug therapy toavoid drug, food, and nutrient al-lergies and interactions

c. Evaluation of all drug therapy tomaximize cost-effectiveness

d. Monitoring all drug regimens forefficacy

e. Monitoring all drug regimens fortoxicity and recommendingmethods for preventing toxicity

f. Detects, evaluates, and reports alladverse drug events

g. Interviewing patients and theircaregivers to obtain an accuratemedication history

h. Evaluation of all enteral and par-enteral nutrition orders for ap-propriateness

i. Providing pharmacokinetic mon-itoring and consultation

j. Providing drug information, in-travenous compatibility informa-tion, and poison information

k. Educating the ICU team mem-bers on pharmacotherapy issues

3. Documents pertinent pharmaceuti-cal care recommendations in themedical record.

4. Participates on various institutioncommittees that involve drug-relatedissues in the critically ill, such as phar-macy and therapeutics, intensive carecommittee, adverse drug reactions,and advanced cardiac life support.

5. Participates in medication use eval-uations and quality assurance activ-ities.

6. Coordinates the development andimplementation of drug-related pol-icy, procedures, guidelines, proto-cols, and pathways.

7. Collaborates with medical and nurs-ing staff in research endeavors.

APPENDIX 5

The ICU Respiratory CarePractitioner

1. Is a practitioner who is licensed by theState Respiratory Care Board (if appli-cable) and has specialized training orpractice providing cardiorespiratorycare for critically ill patients.

2. In providing cardiorespiratory care,the respiratory therapist is responsi-ble for the following services.a. Evaluation of respiratory therapy

orders for appropriate indication,medication, equipment, and po-tential efficacy

b. Evaluation of orders for mechani-cal ventilatory support for appro-priate indication and implementa-tion

c. Evaluation of all respiratory ther-apy procedures to maximize effi-cacy and cost-effectiveness

d. Monitoring of mechanical venti-latory support to minimize com-plications and maximize thera-peutic goals and to enhancepatient comfort

e. Monitoring of respiratory careprocedures for improving effi-cacy, reducing adverse effects,and assuring safety

f. Detects, evaluates, and reports alladverse events related to me-chanical ventilation and respira-tory care procedures

g. Provides consultation on mechan-ical ventilation, respiratory therapyprocedures, weaning from ventila-tory support, delivery of aerosol-ized medications, airway manage-ment, and novel treatments

h. Educates the ICU team memberson issues related to mechanicalventilation and respiratory careprocedures

3. Documents pertinent respiratorycare recommendations in the medi-cal record.

4. Participates on institution commit-tees that involve respiratory care andmechanical ventilation issues, suchas the cardiopulmonary resuscita-tion committee, pharmacy and ther-apeutics, and intensive care qualityassurance committee.

5. Coordinates the development andimplementation of respiratory careand mechanical ventilation proce-dures, guidelines, protocols, andpathways.


6. Collaborates with medical staff in re-search endeavors.

7. Respiratory care services should beavailable 24 hrs a day, 7 days a week.

APPENDIX 6

Members of the ACCM TaskForce on Models of CriticalCare Delivery

Richard J. Brilli, MD, FCCM, Chair;Philip S. Barie, MD, FCCM; Robert L.Barker, MD, FCCM; Carolyn E. Bekes,MD, MHA, FCCM; David Bigos, MD;Richard D. Branson, RRT, FCCM; GladysM. Campbell, RN, MSN, FCCM; Henry

Cohen, PharmD, MS; Joseph F. Dasta,MSc, FCCM; Charles G. Durbin Jr MD,FCCM; Andrew B. Egol, DO, FCCM;Steven G. Emery; Brenda G. Fahy, MD,FCCM; Barry S. Frank, MD; Bruce T.Gipe, MD; Maureen A. Harvey, RN, MPH,FCCM; John W. Hoyt, MD, FCCM; MarkA. Kelley, MD; Kathleen M. Kelly, MD,FCCM; Mary E. Maniscalco-Theberge,MD; Pamela H. Mitchell, RN, PhD;William T. Peruzzi, MD, FCCM; Maria I.Rudis, PharmD, FCCM; Ramesh C.Sachdeva, MB, BS; Antoinette Spevetz,MD, FCCM; Arthur C. St. Andre, MD,FCCM; Daniel P. Stoltzfus, MD, FCCM;James R. Stone, MD, FCCM; Daniel Teres,MD, FCCM; Barry J. Weled, MD, FCCM.

APPENDIX 7

ACCM Guidelines for theDefinition of an Intensivist andthe Practice of Critical CareMedicine

Antoinette Spevetz, MD, FCCM, Chair;Collin E. Brathwaite, MD, FCCM; RichardJ. Brilli, MD, FCCM; Jay S. Cowen, MD;Daniel L. Herr, MD, FCCM; Arthur C. St.Andre, MD, FCCM; Daniel P. Stoltzfus,MD, FCCM; James R. Stone, MD, FCCM;Judy T. Verger, MSN, CRNP, FCCM;Jonathan Warren, MD, FCCM; Barry J.Weled, MD, FCCM; Marc T. Zubrow, MD,FCCM.
